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The Dysphagia Outcome and Severity Scale

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Dysphagia 14:139145 (1999)
The Dysphagia Outcome and Severity Scale
Karen H. ONeil, MA, Mary Purdy, PhD, Janice Falk, MA, and Lanelle Gallo, MS
Hartford Hospital, Hartford, Connecticut, USA
Abstract. The Dysphagia Outcome and Severity Scale
(DOSS) is a simple, easy-to-use, 7-point scale developed
to systematically rate the functional severity of dyspha-
gia based on objective assessment and make recommen-
dations for diet level, independence level, and type of
nutrition. Intra- and interjudge reliabilities of the DOSS
was established by four clinicians on 135 consecutive
patients who underwent a modified barium swallow pro-
cedure at a large teaching hospital. Patients were as-
signed a severity level, independence level, and nutri-
tional level based on three areas most associated with
final recommendations: oral stage bolus transfer, pharyn-
geal stage retention, and airway protection. Results indi-
cate high interrater (90%) and intrarater (93%) agree-
ment with this scale. Implications are suggested for use
of the DOSS in documenting functional outcomes of
swallowing and diet status based on objective assess-
ment.
Key words: Dysphagia Severity Scales Out-
come Videofluoroscopy Reliability Deglutition
Deglutition disorders.
The demand for outcome data in dysphagia research has
elevated in recent years with the expanding presence of
managed care, and the rapidly changing Medicare envi-
ronment. Clinicians are challenged by third-party payers
and physicians to prove the validity and reliability of
dysphagia assessments from which treatment recommen-
dations are made. However, the consistency of documen-
tation in evaluating dysphagia has not been encourag-
ingly high in the dysphagia literature to date. Wilcox et
al. [1] studied interjudge agreement of speech patholo-
Correspondence to: Karen H. ONeil, M.A., Speech Pathology, Hart-
ford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
Springer-Verlag New York Inc. 1999
gists on observation of swallow deficits on videofluoro-
scopic examination and agreement of treatment recom-
mendations. They stated that instances of high agree-
ment among clinicians were not abundant [1]. Ekberg et
al. studied interrater reliability of radiologists on cinera-
diographic assessments and found that interobserver
variability in cineradiographic assessment of pharyngeal
function seems to be a major function of observer expe-
rience [2]. There is also significant demand to deter-
mine the efficacy, effectiveness, and cost benefit of swal-
lowing therapy for large patient populations and within
individual treatment facilities. Currently, there is a pau-
city of research to assuage these demands, and clinicians
have few means of reliably documenting such functional
outcomes.
Other areas in rehabilitation outcomes have been
systematically and internationally studied with the func-
tional independence measure (FIM) [3]. The FIM is one
of the most widely used methods of assessing basic qual-
ity of daily living in persons with disability [4]. The
FIM is a 7-point scale across 18 motor and cognitive/
social areas which allows a patients progress to be
charted reliably across a variety of settings, raters and
patients, as reviewed by Ottenbacher et al., with an
interrater reliability of 8999% [4]. Dysphagia is not
currently an area on the FIM, but it is a common dis-
ability of stroke patients in rehabilitation settings and of
nursing home residents. The occurrence of dysphagia
following stroke has been estimated at approximately
2545% [59]. Moreover, the incidence of dysphagia in
nursing homes has been reported by Donner (1986) as
40% of the population [10]. To address the quality and
efficacy of care in these patients across clinicians and
settings, a reliable and uniform measure of dysphagia
severity is necessary.
Currently there are scales available that clinicians
can use to subjectively qualify the level of dysphagia in
adult populations. However, reliability of these measures
is unknown and there are no correlates to objective per-
140
formance. Cherney et al. described seven functional se-
verity levels of dysphagia based on independence and
nutritional level in the RIC Clinical Evaluation of Dys-
phagia (CED) manual [11]. ASHA is currently field test-
ing the ASHA Functional Communication Measure swal-
lowing subscale for reliability [12]. This 7-point scale
also rates severity based on the patients ability to meet
nutritional needs and independence with compensatory
strategies. These scales do not attempt to relate severity
to objective measures; thus, it is difficult to establish
consistency in the documentation of patient care or cred-
ibly claim significant changes in a patients condition.
A few investigators have developed scales that
relate dysphagia presentation on videofluoroscopic as-
sessment to severity and have then tested agreement;
however, they failed to incorporate functional levels of
independence, diet, and nutrition, and reliability of these
scales has not been especially high. Rosenbek et al. de-
veloped the PenetrationAspiration Scale to describe
penetration and aspiration events and found the interrater
reliability to be 5775% between judge pairs and overall
intrajudge reliability to be 74% for agreement of the
same judge regrading 75 swallows [13]. Ott et al. de-
scribed four levels of severity (03) for a bedside swal-
lowing assessment and modified barium swallow
(MBS): (a) mild dysphagia if bolus control and trans-
port were delayed or if mild stasis occurred without la-
ryngeal penetration, (b) moderate dysphagia included
poor oral transport, pharyngeal stasis with all consisten-
cies, laryngeal penetration or mild aspiration with only
one consistency, and (c) severe dysphagia was present
when substantial aspiration occurred or if the patient
failed to swallow [14]. They then determined agreement
between the bedside and MBS severity ratings as 59%
but did not present inter- or intrajudge reliabilities of the
ratings or the videofluoroscopic examinations.
Daniels et al. developed a five-level severity
scale based on the MBS procedure: 0 (normal), 1 (mild)
with no more than intermittent evidence of trace pen-
etration into the laryngeal vestibule with immediate
clearing, 2 (moderate) as consistent laryngeal penetra-
tion with vestibule stasis and/or 2 or fewer instances of
aspiration with a single consistency, 3 (moderate
severe) as consistent aspiration of a single viscosity,
and 4 (severe) as aspiration of more than one consis-
tency [15]. The interrater reliability of this scale was
found to be 66%, and the intrarater reliability was 80%.
The purpose of this study was to develop an eas-
ily administered, seven-level functional scale that as-
signed severity with acceptable reliability based on re-
sults of the MBS procedure and allowed improved con-
sistency in recommendations for nutrition level, diet, and
independence.
K.H. ONeil et al.: Dysphagia Outcome and Severity Scale
Scale Development
A retrospective and informal analysis of all MBS reports
from a single month showed significant variability across
and within clinicians on what was documented as mild,
moderate, or severe dysphagia. There was also notable
inconsistency in the recommendations for supervision,
diet consistency, and nutritional level based on the docu-
mented MBS findings. The Dysphagia Outcome and Se-
verity Scale (DOSS) was developed by four clinicians in
a large teaching hospital for the purpose of establishing
a consistent method of documentation and improved
quality of care in patients objectively diagnosed with
dysphagia.
The first stage of development of the DOSS in-
corporated three factors previously identified in the lit-
erature that allow for comparison among a wide range of
patients and changes within a single patient over time.
1. Level of independence. The scale was divided into
seven independence levels based on the FIM model
and linked to severity. The initial levels were 7 within
normal limits, 6 (modified independence), 5 (distant
supervision), 4 (intermittent supervision), 3 (total su-
pervision), 2 (maximum assistance), and 1 (depen-
dent/non-per-oral nutrition [NPO]).
2. Level of nutrition. The scale was then divided into the
two possible recommendations for nutrition and were
linked to severity level: levels 73 (full oral nutrition)
and levels 21 (nonoral nutrition).
3. Diet level and diet modifications. Guidelines for diet
modifications were then added for each severity level
that allowed oral intake: levels 76 (normal diet con-
sistency), level 5 (may need one diet consistency re-
striction), level 4 (one to two diet consistency restric-
tions), and level 3 (two or more diet consistency re-
strictions).
The next stage of development focused on objec-
tively defining the characteristics of the impaired swal-
low and determining how the dysphagia would impact
the patients level of independence, nutrition, and diet
recommendations. A careful review of 100 previous
MBS studies was conducted to determine which factors
dictated nutritional status. Of the 100 reports reviewed,
15% were NPO, 65% had recommendations for a modi-
fied diet, and 20% were allowed a normal diet as dictated
by the factors of oral stage transfer, pharyngeal stage
retention, and/or airway penetration/aspiration.
Oral Stage Transfer
Logemann summarized the oral stage as involving in-
tact labial musculature to prevent material from leaking
K.H. ONeil et al.: Dysphagia Outcome and Severity Scale
from the oral cavity, intact lingual movement to propel
the bolus posteriorly, and intact buccal musculature to
insure that material does not fall into the lateral sulci
[16]. Patients in the present study were clinically judged
on the degree of bolus loss or oral retention (after the
swallow) and the patients ability to compensate with or
without cueing. For example, if a patient is unable to
move a bolus posteriorly into the oral cavity or loses the
entire bolus due to poor labial closure, that patient will
have difficulty meeting nutritional needs and would be
considered more severe. However, if that patient is able
to use strategies, verbal cues, or positions to compensate
for that deficit and transfer the bolus through the oral
cavity effectively, that would be considered less severe
but with different levels of assistance needed.
Pharyngeal Stage Retention
Pharyngeal retention is defined as material that remains
in the pharynx (valleculae and/or pyriform sinuses) after
a swallow has been completed. As stated by Cherney et
al., residue may remain in the valleculae and/or pyri-
form sinuses; if particles fall into the airway, aspiration
may occur after the swallow reflex [11]. The impact of
retention on severity of dysphagia was based on the rela-
tive amount of barium retained in the valleculae and/or
pyriform sinuses (mild, moderate, or severe). Further-
more, it considers the patients ability to either clear the
retention automatically with a re-swallow or clear re-
tained material with a re-swallow when cued (told to
re-swallow). For example, if a patient swallows a bolus
but a significant amount is left in pharynx after the swal-
low and no attempts to clear the material is made even
with cues, the patients ability to maintain nutrition
safely is considered severely impaired. However, if that
same patient is able to clear the retention spontaneously
or with cued re-swallows or compensatory strategies, the
impact of that retention is considered less severe.
PenetrationAspiration
Airway penetration is defined as material that enters the
airway into the laryngeal vestibule, above or to the level
of the vocal cords. Aspiration is defined as material that
goes into the trachea, below the level of the vocal cords.
These terms were defined in a similar way by Rosenbek
et al. [13]. The following factors were considered in
determining diet recommendations: the number of con-
sistencies penetrated or aspirated, the presence or ab-
sence of a reflexive and/or elicited cough to clear pen-
etration or aspiration, and the level to which the material
penetrated into the airway. If a patient aspirated on all
consistencies and did not or could not cough to clear the
aspirated material, this was considered very severe and
141
would impact that patients ability to tolerate any con-
sistency effectively. If that same patient was able to use
a strategy to eliminate aspiration with at least one con-
sistency, oral intake might be possible with assistance.
The impact of that aspiration on nutrition, diet, and in-
dependence would be considered less severe. The sever-
ity of penetrationaspiration was based on retrospective
report analysis and through the general framework pro-
posed by Rosenbek et al. in their study on the penetra-
tionaspiration scale [13].
Once the scale was fully outlined incorporating
all these factors, it was piloted for approximately 1
month, with ongoing changes made until the final revi-
sion was completed (Table 1).
Subjects and Methods
The results of 135 consecutive patients in a 3-month period to undergo
an MBS procedure at Hartford Hospital, representing a wide range of
acuity and diagnoses (Table 2), were examined. Neurological diag-
noses included stroke, neurosurgery, Parkinsons disease, dementia,
encephalopathy and traumatic brain injury, muscular dystrophy, etc.
General medical/surgical diagnoses included gastrointestinal disorders
(gastrointestinal bleed, esophagi, small bowel obstruction, etc.), HIV,
sepsis, renal and urological disorders, diabetes, dehydration, malnutri-
tion, all general surgery (with the exception of cardiac and neurologi-
cal), etc. Pulmonary patients included persons with pneumonia, chronic
obstructive pulmonary disease, asthma, respiratory failure, pleural ef-
fusions, etc. Cardiac patients included patients who had a myocardial
infarction, open heart surgery, congestive heart failure, coronary artery
disease, carotid endarterectomy, heart transplant, etc. (without neuro-
logical event). Ear, nose, and throat (ENT) diagnoses included laryn-
geal cancer, vocal cord paralysis, and polyps. Other diagnoses were
psychiatric.
The subject group included 57 women and 78 men and was a
sample of acute care patients, outpatients, and acute rehabilitation pa-
tients. The patients ages ranged from 21 to 95 years, with a mean age
of 73 years. The DOSS was used to assign a severity level once the
objective assessment had been determined by the speech pathologist
and the radiologist. The videofluoroscopic swallowing assessments fol-
lowed hospital protocol adapted from Logemanns procedures [7]. A
full medical history was obtained prior to examination, and an oral
motor/voice examination was completed. Patients were given barium in
thin, medium, thick, puree, and solid consistencies as per their ability
to swallow. Review of the videotape was completed and documented
on a report form according to department protocol (Table 3).
Once the report was completed and severity assigned, a copy
was made of the contents (Table 3) for each patient. This copy was
randomly given to one of the three other trained speech pathologists
who then blindly assigned severity level based on the DOSS. The report
was then given back to the original clinician for intrajudge rating after
a period of 24 weeks, and a severity level was blindly assigned based
on the contents presented in Table 3.
Training
All participating speech pathologists underwent training
in using the DOSS. Specific instruction in the guidelines
for use included careful attention to severity level head-
142 K.H. ONeil et al.: Dysphagia Outcome and Severity Scale

Table 1. Dysphagia outcome and severity scalefinal revision

Full per-oral nutrition (P.O): Normal diet

Level 7: Normal in all situations

Normal diet
No strategies or extra time needed
Level 6: Within functional limits/modified independence
Normal diet, functional swallow
Patient may have mild oral or pharyngeal delay, retention or trace epiglottal undercoating but independently and spontaneously
compensates/clears
May need extra time for meal
Have no aspiration or penetration across consistencies
Full P.O: Modified diet and/or independence

Level 5: Mild dysphagia: Distant supervision, may need one diet consistency restricted
May exhibit one or more of the following
Aspiration of thin liquids only but with strong reflexive cough to clear completely
Airway penetration midway to cords with one or more consistency or to cords with one consistency but clears spontaneously
Retention in pharynx that is cleared spontaneously
Mild oral dysphagia with reduced mastication and/or oral retention that is cleared spontaneously
Level 4: Mildmoderate dysphagia: Intermittent supervision/cueing, one or two consistencies restricted
May exhibit one or more of the following
Retention in pharynx cleared with cue
Retention in the oral cavity that is cleared with cue
Aspiration with one consistency, with weak or no reflexive cough
Or airway penetration to the level of the vocal cords with cough with two consistencies
Or airway penetration to the level of the vocal cords without cought with one consistency
Level 3: Moderate dysphagia: Total assist, supervision, or strategies, two or more diet consistencies restricted
May exhibit one or more of the following
Moderate retention in pharynx, cleared with cue
Moderate retention in oral cavity, cleared with cue
Airway penetration to the level of the vocal cords without cough with two or more consistencies
Or aspiration with two consistencies, with weak or no reflexive cough
Or aspiration with one consistency, no cough and airway penetration to cords with one, no cough
Nonoral nutrition necessary

Level 2: Moderately severe dysphagia: Maximum assistance or use of strategies with partial P.O. only (tolerates at least one consistency safely
with total use of strategies)
May exhibit one or more of the following
Severe retention in pharynx, unable to clear or needs multiple cues
Severe oral stage bolus loss or retention, unable to clear or needs multiple cues
Aspiration with two or more consistencies, no reflexive cough, weak volitional cough
Or aspiration with one or more consistency, no cough and airway penetration to cords with one or more consistency, no cough
Level 1: Severe dysphagia: NPO: Unable to tolerate any P.O. safely
May exhibit one or more of the following
Severe retention in pharynx, unable to clear
Severe oral stage bolus loss or retention, unable to clear
Silent aspiration with two or more consistencies, nonfunctional volitional cough
Or unable to achieve swallow

ings and discriminating factors to consider when decid-
ing between levels (patients environment, premorbid
nutrition, cognition, acuity of dysphagia, current medical
status). These factors are integral to a careful decision-
making process for level of nutrition, diet, and indepen-
dence and were assessed by chart review, history intake
with the patient, and clinical bedside evaluation.
The patients environment is defined as the
amount of supervision that is realistically available for
that patient. For example, the speech pathologist can bet-
ter decide between level 2 (nonoral intake) and level 3
(oral intake with total assistance for strategies) when
accurate and realistic consideration of possible supervi-
sion is known. Premorbid nutrition is also very pertinent
to making difficult decisions between recommending full
oral intake versus nonoral intake. A patients ability to
K.H. ONeil et al.: Dysphagia Outcome and Severity Scale 143

Table 2. Patient diagnoses

Diagnosis Neurological General medical/surgical Pulmonary Cardiac ENT Other

n (%) 81 (60) 32 (24) 10 (7) 8 (6) 3 (2) 1 (1)

Table 3. Report format

Medical summary: Current diet:

Mental status: AlertLethargicOrientedConfusedCooperativeUncooperativeFollows commands/spontaneously with cues
Does not follow commands

Thin Nectar Honey Puree/ Soft Hard

Oralmotor Intact Impaired Nonfunctional Phase liquid liquid liquid pudding solid solid

Swallow reflex Oral

Volitional cough Leakage L/R lip
Reflexive cough Poor bolus formation
Lip closure Poor bolus propulsion
Lateral tongue Retention L/R sulcus
Anterior tongue Poor velopharyngeal closure
Posterior tongue Pharyngeal
Mandible Delayed pharyngeal swallow
Voice Reduced laryngeal elevation
Dentition/dentures Reduced epiglottal tilt
Reduced pharyngeal peristalsis
Cricopharyngeal dysfunction
Retention valleculae
Spontaneously cleared
Cleared with cue
Unable to clear
Retention pyriform
Spontaneously cleared
Cleared with cue
Unable to clear
Aiway penetration
Midway to cords
To cords, spontaneous cough
To cords, no cough
Eliminated with compensatory strategy
Aspiration
Productive spontaneous cough
Nonproductive cough
No cough (silent)
Eliminated with compensatory strategy

maintain oral nutrition before dysphagia will only be-
come more problematic with the onset of difficulty in
swallowing. Cognition also is important to consider
when deciding whether a patient will quickly and spon-
taneously learn strategies (level 6) or need supervision
due to poor memory (level 5 or below). Acuity of dys-
phagia refers to how acute the swallowing problem is to
the patient, and current medical status refers to the rela-
tive acuity of the overall medical issues. These factors
are critical in considering the risks that are considered
with a given patient and may guide a clinician toward a
more conservative stance on a patient with multiple cur-
rent medical concerns.
Following verbal instruction in the guidelines for
use of the DOSS, a peer review of videotaped MBS
studies with joint scorings was conducted. All discrep-
ancies in scoring were discussed and resolved.
Results
Results are presented in Tables 4 and 5 and outline the
different types of reliability established (interjudge or
144
between two judges and intrajudge or between two grad-
ings by a single judge). Table 6 shows the number of
patients for each severity level and the reliability figures
for each severity level.
Of the 135 consecutive patients who underwent
an MBS procedure, 10 (7%) were rated as severe and 17
(12.6%) were rated as moderately severe by the initial
rater; all required nonoral nutrition according to recom-
mendations. Twenty-one (15.6%) of the 135 patients had
moderate dysphagia, 30 (22%) were rated as mild to
moderate, and 28 (21%) were considered to have mild
dysphagia; recommendations for these three groups al-
lowed full oral nutrition but with a restricted diet and
level of independence. A functional swallow was deter-
mined in 22 (16%) of the 135 patients, and seven (5%)
were rated as normal; both groups were allowed a normal
diet based on recommendations from the DOSS. (Ta-
ble 6).
On overall interrater reliability, both judges
agreed and assigned an exact match for 121 of 135 cases
(90%). The four judges constituted three judge pairs, and
the individual agreement between the two judges in each
pair is outlined in Table 4. The scores that disagreed
were off by one level on the scale in 13 of 14 instances
of error, and all were within two severity levels. As cited
in Table 6, interjudge agreement was good for rating all
levels of the scale (82100%), with the highest concor-
dance on level 7/normal (100%), level 4/mildmoderate
(93%), level 6/within functional limits (91%), and level
1/severe (90%).
Total intrajudge reliability was 93% (125 of 135)
when the four judges reassigned the same severity level
on the second grading. Table 5 summarizes the pattern of
agreement for each individual judge. Reliability was
good across all levels of the scale (86100%). The sec-
ond ratings that did not agree were off by only one se-
verity level in six of nine cases, and all disagreements
were within two severity levels (Table 5).
Discussion
The purpose of the present study was to develop a scale
to rate the severity of dysphagia and functional level
based on objective measures from the MBS procedure
and to determine the reliability of the scale for an ac-
ceptable number of subjects. The scale was not intended
to determine reliability of the MBS procedure itself. It
was intended, however, to improve the consistency of
documentation and recommendations across clinicians
and within individual clinicians, provide a basis for com-
paring patients with each other and over time, and to
introduce a possible measure of functional outcomes in
dysphagia. The present results indicate that the DOSS
K.H. ONeil et al.: Dysphagia Outcome and Severity Scale
Table 4. Interjudge reliability by judge pair
12 13 14 Total
Total rated 43 57 35 135
No. ratings agree 37 52 32 121
Reliability % 86 91 91 90
Scores that differed
by 1 (%) 6/6 (100) 5/5 (100) 2/3 (66) 13 (93)
Scores that differed
by 2 (%) 0 0 1/3 (33) 1 (7)
can be used by trained clinicians to better describe se-
verity level of dysphagia with excellent reliability and to
make more consistent recommendations for nutrition,
diet, and independence.
Scale development and use are founded on strong
documentation of MBS results on a detailed report for-
mat and training with discriminating factors critical to
appropriate recommendations. These factors include the
patients premorbid nutrition level, acuity of dysphagia,
current medical status, environment, and cognition. Use
of this scale may improve and highlight clinical attention
to important subtleties of assigning diagnosis and could
also improve communication between clinicians and al-
low a smoother continuum of care for dysphagic patients
across settings. This improved consistency of documen-
tation and recommendations would serve this area of our
profession well in a time that demands larger scale stud-
ies of efficacy, efficiency, and outcome.
However, the scale does not thoroughly define
each parameter (i.e., what constitutes mild retention)
and therefore requires subjective clinical determination
usually based on clinical experience. A clearer definition
of what determines such parameters as severe aspira-
tion or severe retention is also needed from future
studies. Also, the present study assessed reliability by
review of written report; therefore, reliability of the ac-
tual interpretation of the videotape and subsequent docu-
mentation was not determined. Further research is nec-
essary to determine the reliability of clinicians interpre-
tation and documentation of MBS results using more
standardized report formats such as the one used in the
present study.
The DOSS may be an excellent and thorough
alternative to currently available scales to describe
functional dysphagia severity. Existing scales have re-
lied on too general and subjective descriptions per level,
have failed to encompass all important dysphagia issues,
or have not presented acceptable levels of reliability.
Both the Cherney et al. scale [11] and the ASHA scale
[12] are 7-point severity scales that assign severity based
on nutritional and independence levels but do not
associate each level with patients dysphagia deficits
K.H. ONeil et al.: Dysphagia Outcome and Severity Scale 145

Table 5. Intrajudge reliability by judge

1 2 3 4 Total (all judges)

Total rated 73 20 27 15 135

No. ratings agree 71 17 24 13 125
Reliability % 97 85 89 87 93
Scores that differed by 1 (%) 1/2 (50) 2/3 (66) 3/3 (100) 0 6 (60)
Scores that differed by two (%) 1/2 (50) 1/3 (33) 0 2/2 (100) 4 (40)

Table 6. Number of patients and reliability by severity level References

1 2 3 4 5 6
n 10 17 21 30 28 22
Interjudge reliability % 90 82 90 93 86 91
Intrajudge reliability % 100 88 90 97 93 86
that can be objectively and consistently measured. The
aspirationpenetration scale by Rosenbek et al. [13]
provides excellent delineation of severity of airway
penetration. However, interrater reliability was only
fair (5775%), and it did not allow for overall function-
al severity of dysphagia as a whole or address regularity
of diet, nutrition, or independence recommendations.
Similarly, the scale by Daniels et al. [15] specifies the
severity level in terms of penetrationaspiration with fair
reliability (66%). However, it neglects other key compo-
nents of both objective severity (retention, oral stage
deficits) and functional parameters (independence, nutri-
tion, diet).
This study has succeeded in presenting a more
functionally holistic and objective DOSS that addresses
all these areas. The DOSS can be used within 5 min by
trained clinicians to determine severity of dysphagia
based on objective measures. In addition, the DOSS was
proven to have excellent interrater (90%) and intrarater
(93%) reliabilities congruent with that of the internation-
ally recognized FIM [3]. Given the high reliability of the
DOSS, this tool could be valuable in objectively mea-
suring the natural history and outcome of dysphagia
across populations and in measuring efficacy of treat-
ment. Further studies are still needed with larger groups
of patients and longitudinally following patients across
time.
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